A Presentation by Strategic Innovation Management, LLC

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1 A Presentation by

2 Increasing and aging population is accelerating health services demand; Hospital admissions increase after 50 years of age Increasing numbers of uninsured persons=reduced access to services; Health care costs increasing faster than those of other economic sectors Large portion of health services paid for by government Public & private insurance waste, fraud and discrimination Fragmented industry with inefficiencies and waste Population increasingly unhealthy 2

3 Institutional focus on cost savings has led to: Competition among charitable organizations and curtailment of their services and service quality; Incentives for insurance companies to restrict benefits paid for with premiums; Incentives for physicians to specialize in order to increase revenues; and consequently, A need for more primary care physicians. There is no national system for preventive services 3

4 Commonwealth Fund ranks NJ nationally: 27 th for access to services 47 th for Children 21 st for prevention 41 st for children requiring mental health care, 37 th for children with a medical home 48 th for potentially avoidable use of hospitals and costs of care 50 th for Medicare reimbursements per enrollee 46 th for long term care residents with a hospital admission 45 th in breast cancer deaths per 100,000 female population 29 th for children s obesity 4

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7 Control costs; Reform wasteful practices with better management, evaluation and quality improvement; Initiate new practices and service models (including some experimentation); Strong emphasis on prevention; Improve transparency of operations; Integrate health services to improve access and continuity of care. 7

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9 The Law is Passed National Regulations, Policies and Guidelines Follow: Definitions & Intended Funding are Stated Oversight Organizations Created: Commissions and Task Forces Calendar of Implementation Including Demonstrations declared: ] Immediate Federal Implementation commences for some programs, studies and demonstration projects. 9

10 Follows Federal Policies and Organizes to Address Requirements of the Law State Passes Required Legislation and Regulations Prevention, Chronic and Public Health Insurance Exchanges Medicaid Regulations and Waivers Accountable Care Studies and Selects Options Available INFORMATION HARD TO GET 10

11 I- Quality, Affordable Care for all Americans (Primarily Reforms and Changes to Insurance) II- Public Programs (Medicaid and related services) III-Improving the Quality and Efficiency of Health Care (Evaluation, Oversight, Reporting, Quality Improvement, and other contemporary management techniques.) IV Prevention of Chronic Disease and Improving Public Health Private and public 11

12 V Health Care Workforce (Support existing and increase supply with appropriate skills) VI- Transparency and Program Integrity (Require reports by provider on their measured results and make resulting information public) VII- Improving Access To Innovative Therapies VIII- CLASS ACT- Now rescinded Provides for voluntary insurance in community living settings, and during emergencies. IX- Revenue Provisions 12

13 Primarily addresses insurance reforms: Creates Insurance Exchanges and provides for consumer information Specifies Insurance Policy Requirements (Guaranteed Coverage Availability, Quality of Care, Prohibition of Discriminations, mandated dependent coverage, etc.) Makes Employer Requirements and Tax Credits Makes Individual Requirements and Mandates Requires reporting of coverage benefits leading to improved outcomes, reduced readmissions, patient education, improved patient safety, wellness and health promotion activities. 13

14 Medicaid for Population up to 133% of Poverty Income Premium Assistance for Employer Based Insurance Additional Support for Children (NJ Family Care) Hospitals may exercise Medicaid presumptive eligibility Coverage for freestanding birth centers Home and Community Services Support and Barrier Reduction (Includes development of formal evaluation and data collection) State eligibility for family planning services Increased Support for aging and disabled Long Term Care Improvements for home and community services 14

15 Prescription Drugs Rebates, Discounts, and Elimination of Exclusions Hospital Disproportionate Share Review and Adjustments Integration and management of Medicaid and Medicare dual eligible beneficiaries Hospital Disproportionate Share funding adjustments Development of Adult Health Quality Measures Payment adjustment for health care acquired conditions Personal Responsibility and Education Health Homes for Low Income People with Chronic Conditions (State Option) 15

16 Grants for Early Childhood Visitation Programs to include maternal and prenatal health, parenting, infant and child health development, school readiness and reduction in child abuse, neglect and injuries. Research and services for postpartum depression Personal responsibility education for adolescents (teen pregnancy) DEMONSTRATION PROJECTS Integrated Care among Hospitals and Community Settings Medicaid Global Payment System (from fee for service to capitated payment Pediatric Accountable Care Medical Emergency Psychiatric 16

17 MAJOR IMPACT Created a National Strategy for Quality Improvement in Healthcare and an Interagency Working Group on Health Care Quality - Establishes, among other subjects, national priorities, and measures for services, health plans, patient functional status outcomes, population health, management and coordination of services, transitions across providers. Enforcement will affect most health services. Measures and reports to be made public. State and federal activities to be coordinated Linked to payment for services Includes incentives and penalties for hospital and licensed facility performance based on performance standards and measures; An initial focus on hospital re-admissions, infections, cardiac diagnoses, pneumonia, surgeries 17

18 Strategic Priorities - Improve health services outcomes and efficiency - Identify system elements that are likely to achieve rapid improvement - Address gaps in quality, efficiency, health outcome information and data aggregation - Link federal payments to quality and efficiency - Enhance healthcare data for quality improvements - Improve Quality Improvement research - Reduce disparities - Reduce medical errors and re-admissions 18

19 Physicians required to make quality reports of their services and outcomes - to be made public based on measured performance - Use of electronic health records - Will produce a database of comparative physician experience using resources Quality measures developed and to be reported will also apply to long term care, rehabilitation hospitals, hospice, skilled nursing, and home health. 19

20 Intends the creation of new patient payment and service delivery models with incentives for their achievement, i.e. - Medical Homes - Community Based Care -Post acute hospital coordinated care -Linking evidence based cancer care to patient incentives 20

21 Medicare Shared Services Program - Accountable Care Organizations Savings obtained from providing services at lower than historical costs are shared with efficient and innovative providers 21

22 Integrated Care and Payment Bundling - Payment for combined inpatient and outpatient services on the basis of episode groups -Demonstration Programs to pave the way Community Based Care Transition Program - For high risk Medicare patients to receive healthcare services at home to prevent their readmissions Healthcare Systems Research Medicare Advisory Board created to advise Medicare policy and budget 22

23 Establish Community Health Teams to Support the Patient-Centered Medical Home Create Interdisciplinary teams of health care providers (which are the medical home) Purpose: care management, education and prevention initiatives Uses continuous quality improvement techniques Home paid for on capitated basis 23

24 Created National Prevention, Health Promotion and Public Health Council Developing a National Strategy for Health Promotion, Prevention, Public Health and Integrative Care to Improve the Health of Americans and Reduce the Incidence of Preventable Illness and Disability 24

25 25

26 Identifies Tobacco Use, Sedentary Behavior and Poor Nutrition as the subject of Wellness, Health Promotion and Public Health Goals -Now being implemented in New Jersey (!!!) Creates a Prevention and Public Health Fund to provide an expanded and sustained national investment in prevention and public health programs. 26

27 Creates the Community Transformation Program and the Education and Outreach Campaign for Preventive Benefits, and Immunization Programs (!!!) Creates the Preventive Services Task Force -Produces a Guide to Clinical Preventive Services for science based best practices Creates an independent Community Preventive Services Task Force -Produces a Guide to Community Preventive Services (!!!) 27

28 Initiates the Education and Outreach Campaign Regarding Preventive Benefits A public/private partnership for prevention and health promotion, outreach and education. Promotes use of preventive services recommended by the U.S. Preventive Services Task Force and the Community Preventive Services Task Force 28

29 Creates the School Based Health Centers Physical and Mental Health Comprehensive provision of health services Focus on areas of special need 29

30 Creates the Oral Healthcare Prevention Program -Education program Creates the Medicare Annual Wellness Visit - Results in a personalized prevention plan based on a persons risk profile (!!!) 30

31 Removes barriers to preventive services in Medicare Improves access to preventive services for eligible adults in Medicaid Provides tobacco cessation services for pregnant women Provides incentives for prevention of chronic diseases in Medicaid 31

32 Creates Community Transformation Grants Dissemination of evidence based community preventive health activities to: Reduce chronic disease Prevent development of secondary conditions Address health disparities Develop a stronger evidence base of effective prevention programming Being Implemented now in New Jersey 32

33 Create Healthy Aging, Living Well Program (!!!) Directed to people years of age Improve nutrition Increase physical activity Reduce tobacco and substance abuse Improve mental health Promote healthy lifestyles Conduct screenings 33

34 Public Health Intervention Program Grants for working with community health centers, rural health clinics, and mental health and substance abuse service providers to assist referrals of at risk patients. (!!!) Removing Barriers and Improving Access to Wellness for Individuals with Disabilities 34

35 Immunization (!!!) Demonstration program to improve immunization coverage Nutrition Labeling of Standard Menu Items at Chain Restaurants Demonstration Project Concerning Individualized Wellness Plans 35

36 Research on Optimizing the Delivery of Public Health Services. (!!!) -Evidence based prevention - Identifying strategies for organizing, financing and delivering public health services in real world community settings. Data Collection, Analysis and Quality 36

37 CDC Employer Wellness Programs (!!!) Provides employers with technical assistance for wellness programs Prevention, Chronic and Public Health Childhood Obesity Demonstration project 37

38 Establish National Health Care Workforce Commission Assess national need for healthcare workforce Increase supply of qualified workforce to improve access Enhance workforce training and education (!!!) Provide assistance to existing workforce (!!!) Promote positive health behaviors and outcomes (!!!) 38

39 Elder Justice Create Elder Justice Coordinating Council Studies elder abuse, neglect and exploitation, and other crimes against elders. Makes short and long-term multi-disciplinary strategic plans for the development of the field of elder justice. (!!!) Provides grants to State Adult Protective Services (!!!) 39

40 Makes publication requirements for information reporting payment transactions between physicians and manufacturers Includes reporting of drug sample practices by pharmaceutical firms and pharmacists 40

41 Will consider creating standards for and safety of biological products intended to be used as alternatives to currently approved products. 41

42 Community Living Assistance Services and Support Establish a national voluntary insurance program for purchasing community living assistance services and supports: To promote independence of individuals with functional limitations. The CLASS program is designed to expand options for people who become functionally disabled and require long-term services and supports. 42

43 Hospital Community Assessment Requirement Miscellaneous fee requirements and eliminations 43

44 44

45 Robert Wood Johnson Foundation RWJF News Digests RWJF Publications Status of the law U.S. Department of Human Services Commonwealth Fund Shaping New Jersey NJ Healthy Aging 45

46 The Full Affordable Care Act Community Catalyst 46

While health care reform has its foundation and framework at

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